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Transitional Care Planning

Transitional Care Planning Assessments

An assessment collects information that helps the health care team identify and manage problems a patient may have in adjusting to a change in care.

Having cancer affects more than the patient's physical condition. It also affects mental health, family life, ability to work, financial planning, social relationships, and faith. Many patients will encounter problems in one or more of these areas as they transfer from one level of care to another. For example, a patient’s family may have problems obtaining special home equipment or learning to use special equipment. Another patient may have a difficult time accepting the change from anticancer care to symptom relief alone, such as that provided with some types of palliative or hospice care. Transitional care planning is unique to each patient and family. Assessments help identify patients who may have problems during the transition and help determine the kind of support they will need to make the change go smoothly. The assessments may include a complete medical history; a physical exam; a test of learning skills; tests to determine ability to perform activities of daily living; a mental health evaluation; a review of social support available to the patient; and referral to community resources as needed to assist with issues such as transportation, home care, healthy eating, and medication management.

Assessments are done many times during the patient's cancer experience, as a routine part of care.

Assessments are done when the patient moves from one facility to another, such as from hospital to home. They are also done at regular times during the course of the disease, usually at the time of diagnosis, after completing a course of treatment, when there is a relapse, when curative treatment stops, and when treatment is discontinued (end-of-life care begins). The patient may feel added emotional stress at these times. Regular assessments can identify these and other causes of distress in the patient, such as job loss or the death or illness of a patient's loved one or caretaker. (See the PDQ summary on Grief, Bereavement, and Coping With Loss for more information.)

Because no one knows what the patient’s needs will be in the future, assessments are done many times during the cancer experience as a routine part of care. This is helps ensure the patient receives the right services at the right times.

All members of the patient’s health care team are involved in the assessment process.

In planning for a change in cancer care, doctors, nurses, and other members of the patient’s health care team will consider all the areas of a patient’s life that may be affected. The following professionals may each conduct different parts of the transitional care planning assessment:

The following types of assessments will be done for transitional care planning:

Physical assessment

A physical assessment will look at the patient's general health, treatment plan, and changes in disease status, including the following factors:

See the following PDQ summaries for more information:

Family and home assessment

Factors such as the patient's age and living arrangements may affect how easily a change in level of care can be accomplished. The assessment will look at the following:

Mental health assessment

Change can be a stressful time for both the patient and family. The nature of the relationship between the patient and his or her family and others helps determine the kinds of services the family may need to cope with the transition. The following questions may be asked:

See the following PDQ summaries for more information:

Social assessment

Doctors and other health care professionals can provide referrals to supportive services available to the patient. A review of the kinds of social services already available to the patient will be done:

Spiritual assessment

Knowing the role that religion and spirituality play in the patient's life help the health care team understand how these beliefs may affect the patient's transition to a new level of care. A spiritual assessment may include the following questions:

Most hospitals, especially larger ones, employ hospital chaplains who are trained to work with medical patients and their families. Hospital chaplains are trained to be sensitive to a range of religious and spiritual beliefs and concerns.

(See the PDQ summary on Spirituality in Cancer Care for more information.)

Legal assessment

Advance directives and other legal documents can help doctors and family members make decisions about treatment should the patient become unable to communicate his or her wishes. The patient may be asked if he or she has prepared any of the following documents: